Withdrawal Of Life Support Research Articles

Utilization rates and heart transplantation outcomes of donation after circulatory death donors with prior cardiopulmonary resuscitation.

Heart donation after circulatory death (DCD) involves mandatory exposure to warm ischemic injury (WII) due to donor cardiac arrest resulting from withdrawal of life-support (WLS). However, potential DCD donors may also experience a cardiac arrest and undergo cardiopulmonary resuscitation (CPR) and associated WII before WLS. We sought to investigate the effect of previous donor-CPR in DCD heart-transplantation (HT). Between January-2020 and April-2023, we identified 11,415 adult HTs in UNOS of whom 9456 met study criteria and had information on donor-CPR. Follow-up was available till April-2024. Study cohort was divided into four groups based on DCD vs. donation after brain death (DBD) status and donor-CPR i.e., DCD/CPR+ (n = 387), DCD/noCPR (n = 305), DBD/CPR+ (n = 5158) and DBD/noCPR (n = 3606); and compared for HT characteristics and outcomes. With DBD/noCPR HTs as reference cohort, there were no significant differences in mortality in other HT cohorts (DCD/CPR+, DCD/noCPR and DBD/CPR+) upto 1-year of follow up using Kaplan-Meier analysis; and both unadjusted and adjusted Cox hazards-ratio models. Results were similar in propensity-matched cohorts. Duration of donor-CPR (≤20 min vs >20 min) did not influence HT survival; and rates of in-hospital secondary outcomes were similar. The utilization rates of both adult DCD/CPR+ (3.39 % to 9.71 %) and DCD/noCPR donors (4.41 % to 10.34 %) increased significantly (p < 0.01) during study period. The utilization rates of both DCD/CPR+ and DCD/noCPR donors have increased at an equal pace. A significant proportion of DCD HTs were from donors with prior CPR, but this was not associated with worse short-term survival.

Abstract 4145896: Terminal Rhythm of the Worldwide First Genetically Modified Porcine-to-Human Xenotransplantation

Background: The worldwide first genetically modified porcine-to-human cardiac xenotransplantation was successfully performed in January 2022 at the University of Maryland with the recipient surviving 60 days. Aim: Assess the ECG parameters and cardiac rhythm during the death of the worldwide first porcine-to-human xenotransplant. Methods: Continuous 6-lead ECG telemetry was used to analyze ECG parameters and cardiac rhythm during the final 9 minutes after withdrawal of life support. Results: At the time of withdrawal (W), the patient was in sinus rhythm (70bpm, PR interval 280ms, right bundle branch block (RBBB) with QRS 140ms, QT 400ms; Figure). PR prolongation up to 360ms with loss of P wave was noted at W+2:55min. Irregular junctional rhythm with blocked PACs and bradycardia (23 bpm) occurred around W+3:25min. At that time, widening of RBBB to 160ms with non-specific repolarization abnormalities and QT prolongation were observed. At W+4:30min, increasing pauses of up to 8.5s with mild QRS axis shift occurred. At W+6min, asystole (up to 20s) with rare PVCs from the left anterolateral LV base were seen. Final rhythm at W+6min consisted of ventricular escape beats from the infero-basal LV before electrical activity ceased at W+6:45min. No other atrial or ventricular arrhythmias were noted. Conclusion: The porcine-to-human cardiac xenotransplant showed a terminal rhythm of bradycardia, sinus arrest, and junctional and ventricular escape beats. This is consistent with ischemia-related failure of impulse generation, slowing intra-atrial/AV-conduction delay, and failure of impulse propagation. Notably, no tachyarrhythmias were seen despite ectopic atrial and ventricular beats with prolongation of depolarization and repolarization. This is similar to traditional terminal rhythms observed in humans and does not suggest unexpected arrhythmic proclivities between pig myocardium and the human environment (“pig heart in human body”).

Requesting Relatives' Consent for Intensive Care for Organ Donation: An Empirical Analysis of Spanish Transplant Coordinators' Practices.

Intensive care to facilitate organ donation (ICOD) involves the initiation or continuation of intensive care for patients with devastating brain injury for donation purposes. In the Spanish system, relatives undergo an early interview to request consent for this procedure. If they consent, a waiting time is agreed upon in the expectation that death by neurological criteria occurs and donation after brain death takes place. Otherwise, relatives can decide on donation after circulatory determination of death or withdrawal of life support. This study analyzes how Spanish transplant coordinators interact with relatives in early interviews and follow-ups on potential donation pathways. Semistructured interviews were conducted with a random stratified sample of 23 Spanish transplant coordination teams to explore strategies, practices, and perceptions of ICOD consent requests. The interviews were recorded, transcribed, and analyzed using content analysis. Previous coordination with other units and information retrieval regarding patient and relatives' situations is crucial. The development of early interviews includes an introduction to the family, identification of decision makers, empathizing with relatives and offering condolences, reaffirming the fatal prognosis, explaining the possibility of donating based on the patient's will, confirming the family's understanding and resolving doubts, and ensuring comfort and assessing family needs. Approaching families to obtain ICOD consent is a regular practice for Spanish coordination teams. It involves a highly professional and diversified set of strategies based on establishing a support relationship for relatives. Our study provides strategies that serve as a reference for obtaining ICOD consent from families in other settings.

Abortion Ban Advocates and Rape Exception.

The present paper argues that abortion ban advocates can justify an exception for rape. Recently, Blackshaw offered an interesting argument that if abortion ban advocates modified their position along the lines of Thomson's analysis of rights, they could make an exception for rape. However, doing so would require making concessions they would be unlikely to make, the crucial one being subscribing to an absurd view that abortion in the case of rape is permissible but only if it is performed in a certain way, that is, in a way that withdraws life support from the fetus. Agreeing first with Blackshaw's premises, we argue that the view in question is hardly absurd. Thus, relying on Boonin's acknowledgment that although very rare, a position according to which abortion should be legal but only if it is performed in a way that lets the fetus die rather than kills it is a possible position, we argue, first, that it is Blackshaw's position that is inconsistent, second, that since deontology sees permissibility of a given result as path-dependent, deontologically oriented abortion ban advocates should find the view in question appealing rather than absurd and, third, that although there are indeed scenarios in which withdrawing life support is morally equivalent to killing, extraction abortions in the case of rape are not amongst them. Since in the case of rape the fetus is not entitled to life support, extraction abortions are better classified as permissible non-omissive allowings than impermissible killings. Thus, there is nothing absurd in the view that abortion in the case of rape is permissible but only if it is performed in a certain way. Accordingly, adopting this view does not seem to be much of a concession for abortion ban advocates who can therefore make an exception for rape.

Association Between Whole Blood Transfusion and Mortality Among Patients With Hemorrhagic Shock and Traumatic Brain Injury.

Whole blood (WB) transfusion in trauma has been revisited, and recent studies have reported an association between WB and improved survival among patients with hemorrhagic shock. However, no evidence of a similar association exists for patients with hemorrhagic shock and traumatic brain injury (TBI). This study aimed to assess the association between WB and mortality among patients with hemorrhagic shock and TBI. This study retrospectively analyzed data obtained from American College of Surgeons-Trauma Quality Improvement Program during January 2020 to December 2021. Patients (age ≥18 years) requiring blood transfusion within 4 hours of hospital arrival and sustaining TBI (head Abbreviated Injury Scale >2) were included. Survival at 30 days were compared after performing 1:1 propensity score matching for demographics, injury type, vital signs on admission, TBI characteristics, injury characteristics, comorbidities, hemorrhage control procedures, hospital characteristics, and withdrawal of life support. A total of 15 967 patients were eligible for analysis. The median age was 42 years (interquartile range: 28-60 years); 11 789 (73.8%) patients were male, and 10 102 (63.2%) patients were White. Of them, 2725 (17.0%) received WB. After a 1:1 propensity score matching, 2720 matched pairs were compared. Matched patients had 1.0 as median shock index and 79 mm Hg as the lowest systolic blood pressure requiring immediate transfusion. WB was not associated with reduced 30-day mortality, compared with non-WB (34.0% vs 34.7%, odds ratio: 0.97, 95% confidence interval: 0.87-1.09). WB was not associated with reduced 30-day mortality among patients with hemorrhagic shock and TBI. These findings suggest that not all patients with hemorrhagic shock would benefit from WB.

Insurance-Related Disparities in Withdrawal of Life Support and Mortality After Spinal Cord Injury

Identifying disparities in health outcomes related to modifiable patient factors can improve patient care. To compare likelihood of withdrawal of life-supporting treatment (WLST) and mortality in patients with complete cervical spinal cord injury (SCI) with different types of insurance. This retrospective cohort study collected data between 2013 and 2020 from 498 trauma centers participating in the Trauma Quality Improvement Program. Participants included adult patients (older than 16 years) with complete cervical SCI. Data were analyzed from November 1, 2023, through May 18, 2024. Uninsured or public insurance compared with private insurance. Coprimary outcomes were WLST and mortality. The adjusted odds ratio (aOR) of each outcome was estimated using hierarchical logistic regression. Propensity score matching was used as an alternative analysis to compare public and privately insured patients. Process of care outcomes, including the occurrence of a hospital complication and length of stay, were compared between matched patients. The study included 8421 patients with complete cervical SCI treated across 498 trauma centers (mean [SD] age, 49.1 [20.2] years; 6742 male [80.1%]). Among the 3524 patients with private insurance, 503 had WLST (14.3%) and 756 died (21.5%). Among the 3957 patients with public insurance, 906 had WLST (22.2%) and 1209 died (30.6%). Among the 940 uninsured patients, 156 had WLST (16.6%) and 318 died (33.8%). A significant difference was found between uninsured and privately insured patients in the adjusted odds of WLST (aOR, 1.49; 95% CI, 1.11-2.01) and mortality (aOR, 1.98; 95% CI, 1.50-2.60). Similar results were found in subgroup analyses. Matched public compared with private insurance patients were found to have significantly greater odds of hospital complications (odds ratio, 1.27; 95% CI, 1.14-1.42) and longer hospital stay (mean difference 5.90 days; 95% CI, 4.64-7.20), which was redemonstrated on subgroup analyses. Health insurance type was associated with significant differences in the odds of WLST, mortality, hospital complications, and days in hospital among patients with complete cervical SCI in this study. Future work is needed to incorporate patient perspectives and identify strategies to close the quality gap for the large number of patients without private insurance.

Profile and Outcome of Patients Admitted to Pediatric Intensive Care Unit at a General Referral Hospital

Introduction: Nepal has made substantial progress in child health primarily through preventive care. There is an increasing need for critical care services across the country which is highly resource intensive. Periodic data of critical care admissions help plan the utilization of scarce resources in a low-income country like Nepal. This study aimed to analyze the epidemiologic patterns of critically ill pediatric patients admitted to the pediatric intensive care unit (PICU). Methods: This descriptive study of all children admitted to PICU at Tribhuvan University Teaching Hospital for 18 months between October 2017 and April 2019 was conducted by a retrospective review of hospital records. Demographic data, etiologies of PICU admissions and outcomes of children admitted to the PICU were analyzed. Results: PICU admitted 413 children during the study duration from all over the country. Children under the age of 2 years (36%) were admitted in the largest number and boys outnumbered girls (65.1%). Respiratory illnesses, neurosurgical and neurological problems, infectious disorders and airway foreign bodies were the most common etiologies for admission. The average length of ICU stay was around 4.4 days. Almost one-third of patients required circulatory and respiratory support. At the time of exit from PICU, 14.3% of patients died; 4.3% patients had opted for withdrawal of life support or decided to leave hospital against medical advice. Conclusion: Patients with diverse etiologies were admitted to ICU from all over the country. A similar analysis from PICUs across the country can serve as the basis for development of newer intensive care facilities in the country, developing dedicated protocols for critical care and redistributing the ICUs’ available resources for optimal efficiency.

In Defense of Normothermic Regional Perfusion.

Normothermic regional perfusion (NRP) is a relatively new approach to procuring organs for transplantation. After circulatory death is declared, perfusion is restored to either the thoracoabdominal organs (in TA-NRP) or abdominal organs alone (in A-NRP) using extracorporeal membrane oxygenation. Simultaneously, surgeons clamp the cerebral arteries, causing a fatal brain injury. Critics claim that clamping the arteries is the proximate cause of death in violation of the dead donor rule and that the procedure is therefore unethical. We disagree. This account does not consider the myriad other factors that contribute to the death of the donor, including the presence of a fatal medical condition, the decision to withdraw life support, and the physician's actions in withdrawing life support and administering medication that may hasten death. Instead, we claim that physicians play a causative role in many of the events that lead to a patient's death and that these actions are often ethically and legally justified. We advance an "all things considered" view according to which TA-NRP may be considered ethically acceptable insofar as it avoids suffering and respects the wishes of the patient to improve the lives of others through organ donation. We conclude with a series of critical questions related to the practice of NRP and call for the development of national consensus on this issue in the United States.

Study Recommends Cautious Delay Before Withdrawing Life Support for Patients With Severe Brain Injury

Study Recommends Cautious Delay Before Withdrawing Life Support for Patients With Severe Brain Injury

Innovative Strategies for Palliative Care in the Intensive Care Unit.

Palliative care is interdisciplinary care that addresses suffering and improves the quality of care for patients and families when patients are facing a life-threatening illness. Palliative care needs in the intensive care unit include communication regarding diagnosis and prognosis, goals-of-care conversations, multidimensional pain and symptom management, and end-of-life care that may include withdrawal of mechanical ventilation and life support. Registered nurses spend the greatest amount of time with patients and families who are facing death and serious illness, so nurses must be armed with adequate training, knowledge, and necessary tools to address patient and caregiver needs and deliver high-quality, patient-centered palliative care. Innovative approaches to integrating palliative care are important components of care for intensive care nurses. This article reviews 2 evidence-based practice projects, a serious illness support tool and the 3 Wishes Project, to add to the palliative care toolkit for registered nurses and other team members.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) in the presence of associated severe traumatic brain injury: A propensity-score matched study

BackgroundExperimental work suggested that resuscitative Endovascular Balloon Occlusion of the aorta (REBOA) preserves cerebral circulation in animal models of traumatic brain injury. No clinical work has evaluated the role of REBOA in the presence of associated severe traumatic brain injury (TBI). We investigated the impacts of REBOA on neurological and survival outcomes. MethodsPropensity-score matched study, using the American College of Surgeons Trauma Quality Improvement Program database. Patients with severe TBI patients (Abbreviated Injury Scale ≥3) receiving REBOA within 4 ​h from arrival were matched with similar patients not receiving REBOA. Neurological matching included head AIS, pupils, and midline shift. Clinical outcomes were compared between the two groups. Results434 REBOA patients were matched with 859 patients without REBOA. Patients in the REBOA group had higher rates of in-hospital mortality (63.6 ​% vs 44.2 ​%, p ​< ​0.001), severe sepsis (4.4 ​% vs 2.2 ​%, p ​= ​0.029), acute kidney injury (10.1 ​% vs 6.6 ​%, p ​= ​0.029), and withdrawal of life support (25.4 ​% vs 19.6 ​%, p ​= ​0.020) despite of lower craniectomy/craniotomy rate (7.1 ​% vs 12.7 ​%, p ​< ​0.002). ConclusionIn patients with severe TBI, REBOA use is associated with an increased risk of in-hospital mortality, AKI, and infectious complications.

Withholding or withdrawing life support in nephrology: a perspective in the French-speaking background

Chronic kidney disease (CKD) characterized by long duration, simplicity at beginning versus complexity at advanced stages. Hemodialysis and peritoneal dialysis are renal replacement therapy allowing life extension, but comorbidities and frailty could be burdensome over time. The academic society, Société Francophone de Néphrologie, Dialyse, Transplantation (SFNDT), publishes clinical practice guidelines to optimize CKD treatment in this context, to support shared decision-making in the appropriate initiation of and withdrawal from dialysis, and to supervise end-of-life cares in the French-speaking countries.

Causes and attributable fraction of death from ARDS in inflammatory phenotypes of sepsis

BackgroundHypoinflammatory and hyperinflammatory phenotypes have been identified in both Acute Respiratory Distress Syndrome (ARDS) and sepsis. Attributable mortality of ARDS in each phenotype of sepsis is yet to be determined. We aimed to estimate the population attributable fraction of death from ARDS (PAFARDS) in hypoinflammatory and hyperinflammatory sepsis, and to determine the primary cause of death within each phenotype.MethodsWe studied 1737 patients with sepsis from two prospective cohorts. Patients were previously assigned to the hyperinflammatory or hypoinflammatory phenotype using latent class analysis. The PAFARDS in patients with sepsis was estimated separately in the hypo and hyperinflammatory phenotypes. Organ dysfunction, severe comorbidities, and withdrawal of life support were abstracted from the medical record in a subset of patients from the EARLI cohort who died (n = 130/179). Primary cause of death was defined as the organ system that most directly contributed to death or withdrawal of life support.ResultsThe PAFARDS was 19% (95%CI 10,28%) in hypoinflammatory sepsis and, 14% (95%CI 6,20%) in hyperinflammatory sepsis. Cause of death differed between the two phenotypes (p < 0.001). Respiratory failure was the most common cause of death in hypoinflammatory sepsis, whereas circulatory shock was the most common cause in hyperinflammatory sepsis. Death with severe underlying comorbidities was more frequent in hypoinflammatory sepsis (81% vs. 67%, p = 0.004).ConclusionsThe PAFARDS is modest in both phenotypes whereas primary cause of death among patients with sepsis differed substantially by phenotype. This study identifies challenges in powering future clinical trials to detect changes in mortality outcomes among patients with sepsis and ARDS.

Asystolic donor warm ischemia time is associated with development of postreperfusion syndrome in donation after circulatory death liver transplant.

Individual events during donation after circulatory death (DCD) procurement, such as hypotensive or hypoxic warm ischemia, or circulatory arrest are all a part of donor warm ischemia time (dWIT), and may have differing effects on the outcome of the liver graft. This study aimed to identify risk factors for postreperfusion syndrome (PRS), a state of severe hemodynamic derangement following graft reperfusion, and its impact on DCD liver transplantation (LT) outcomes. This was a retrospective analysis using 106 DCD LT. Detailed information for events during procurement (withdrawal of life support; systolic blood pressure<80mmHg; oxygen saturation<80%; circulatory arrest; aortic cold perfusion) and their association with the development of PRS were examined using logistic regression. The overall incidence of PRS was 26.4%, occurring in 28 patients. Independent risk factors for PRS were asystolic dWIT (odds ratio (OR) 3.65, 95% confidence interval (CI) 1.38-9.66) and MELD score (OR 1.06, 95% CI 1.01-1.10). Total bilirubin was significantly higher in the PRS group at postoperative day (POD) 1 (p=.02; 5.2mg/dL vs. 3.4mg/dL), POD 3 (p=.049; 4.5mg/dL vs. 2.8mg/dL), and POD 7 (p=.04; 3.1mg/dL vs. 1.9mg/dL). Renal replacement therapy after LT was more likely to be required in the PRS group (p=.01; 48.2%vs. 23.1%). Asystolic dWIT is a risk factor for the development of PRS in DCD LT. Our results suggest that asystolic dWIT should be considered when selecting DCD liver donors.

Ethical issues surrounding appropriate care for older persons in the Intensive Care Unit.

Increasing numbers of older patients are being admitted to the Intensive Care Unit (ICU) as the world's population ages. The biological process of ageing, senescence, results in altered ability to maintain normal homeostasis and organ function, including of the cardiovascular, immune, and neuromuscular systems. This contributes towards increased frailty in older patients, associated with functional limitations and increased vulnerability. Although widely defined using chronological age, the concept of "old age" is thus multifactorial, including biological, but also psychological and sociocultural aspects, which should all be taken into account when considering what is appropriate in terms of ICU admission and management. As for all patients, but perhaps particularly in this subgroup, decisions regarding ICU admission and treatment and the withdrawing and withholding of life support must be individualized.

End-of-life decision-making in the neonatal intensive care unit.

Most paediatric deaths occur in the neonatal period, many of them in neonatal intensive care units after withdrawal of life support or the decision not to initiate new treatments. In these circumstances, discussions with families and decision-making are fundamental elements of the care and attention given to newborn babies. In this context, bioethical deliberation can help us to identify the values at stake, the different courses of action to be taken, and the means to ensure that family-shared decision-making is appropriate to the patient's situation and in accordance with the family's values.

Withdrawing Life Support After Attempted Suicide: A Case Study and Review of Ethical Considerations.

Ethical questions surrounding withdrawal of life support can be complex. When life support therapies are the result of a suicide attempt, the potential ethical issues take on another dimension. Duties and principles that normally guide clinicians' actions as caregivers may not apply as easily. We present a case of attempted suicide in which decisions surrounding withdrawal of life support provoked conflict between a patient's family and the medical team caring for him. We highlight the major unresolved philosophical questions and contradictory normative values about suicide that underlie this conflict. Finally, we show how these considerations were practically applied to this particular case.

Withdrawing Life Support After Attempted Suicide: A Case Study and Review of Ethical Consideration

Ethical questions surrounding withdrawal of life support can be complex. When life support therapies are the result of a suicide attempt, the potential ethical issues take on another dimension. Duties and principles that normally guide clinicians’ actions as caregivers may not apply as easily. We present a case of attempted suicide in which decisions surrounding withdrawal of life support provoked conflict between a patient’s family and the medical team caring for him. We highlight the major unresolved philosophical questions and contradictory normative values about suicide that underlie this conflict. Finally, we show how these considerations were practically applied to this particular case.

The Future of Newborn Genomic Testing.

Genome sequencing (GS) provides exciting opportunities to rapidly identify a diagnosis in critically ill newborns and children with rare genetic conditions. Nevertheless, there are reasons to remain cautious about the use of GS. Studies to date have been mostly in highly selected populations of babies with unusual clinical presentations. GS leads to diagnoses in many such infants. More rarely, it leads to beneficial changes in management. Parents and physicians whose babies meet these criteria and for whom GS is performed both find these results useful. The concern is this: we do not know how useful such testing will be in the general population. We can speculate that a number of problems will arise as the use of GS expands. First, the percentage of cases in which a valid molecular diagnosis is made will likely go down. The number of ambiguous results or false positives will rise. Genetic counseling will become more complex and challenging. We do not know the relative cost-effectiveness of whole genome, whole exome, or targeted panels in different populations. We do not know the relative contribution of a molecular diagnosis to the decision to withdraw life support. We will have to carefully evaluate the use of such testing in order to understand whether it truly improves outcome and survival or reduces symptoms in babies who are tested. Each of these concerns will require careful study of both the technology and the ethical issues to allow us to harness the potential of these new technologies while avoiding foreseeable problems. Studies are underway to see how the tests are used in general populations. These studies should generate important information to guide clinicians and policymakers. As part of informed consent, doctors should explain to parents that genetic results are not always straightforward. Sometimes, they confirm a diagnosis that was already suspected. Sometimes, they rule out a possible diagnosis. Sometimes, the results are ambiguous and difficult to interpret. Anticipatory discussions should try to give parents a realistic understanding of the likely impact of a genetic diagnosis. Diagnostic genomic testing for newborns is a science that is still in its infancy. More research is essential in order to establish how to personalize this promising but sometimes problematic tool.

Heart Transplantation Using Donation After Circulatory Death (DCD) Donors: St Vincent’s Hospital Experience Update

Donation after circulatory death is a technique utilising the heart from donors after withdrawal of life support and requires sustained circulatory cessation prior to organ retrieval. This unit was the first to perform heart transplants utilising distantly procured hearts from donation after circulatory death (DCD) donors in 2014.